Homeowner Insurance Survey

1. What is your full name?

2. What is your Date of Birth?

3. What is your Spouse or Roommate's name?

4. What is your Spouse or Roommate's Date of Birth?

5. Who owns the property to be insured?

6. What is your Mailing Address?

City

State

Zip

Country

7. What is your Facsimile Number?

8. What is your Home Phone Number?

9. What is your Email Address?

10. How did you find out about IRMS?

Family/Friends/Peers Realtor Trade Show/Event Current Client Other (If other please specify below.)

11. How quickly do you need your quotation?

12. When do you want your policy to be effective?

13. Have you, your Spouse, or your Roommate ever been involved in a Bankruptcy or Foreclosure or convicted of Arson or Fraud?

Yes No

14. If yes, provide details.

15. How long have you lived at your current Address?

16. List the insurance company that currently insures the property to be insured.

17. List the expiration date of your current policy.

18. Have you reported any Claims in the past 5 years under any Homeowner's Policy in any state?

Yes No

If yes, provide details.

19. What is the location address of the property to be insured?

City

State

Zip

Country

20. Is the property located in a community or subdivision?

Yes No

If yes, provide the name of the subdivision.

22. What is the occupancy of this property?

Primary Residence Seasonal Residence Rental Vacant

23. Which months during the year do you occupy the property?

24. Do you rent the property?

Yes No

25. If you rent the property, which months during the year do you rent the property?

26. If you rent the property, what is the minimum amount of time (weeks/months/annually) each renter will occupy the property?

27. Is a business operated at this property?

Yes
No

If yes, provide details.

28. How many feet is the property from the nearest fire hydrant?

29. How many miles is the property from the nearest Fire Station?

30. Which Fire Department would respond to this property?

31. Do you own any watercraft or recreational vehicles?

Yes No

If yes to above provide the Year, Make and Model.

32. Do you have a trampoline located at this property?

Yes
No

33. Do you have any pets or other animals living at this property?

Yes No

If yes, list type and breed.

34. Have there been any instances of animals biting anyone?

35. In what year was the property built?

36. How many floors does this property have?

37. Which floor is the unit located on?

38. What is the replacement cost of your Additions and Alterations coverage?

40. How many square feet of air-conditioned space does this property have?

41. Is this property a Condominium Unit?

Yes No

42. If a Condominium, what is the Replacement Cost of the contents to be insured?

43. What is the foundation type?

Stilt (wood or concrete) Crawl Space Concrete Slab

44. What is the construction type?

Fire Resistive (Concrete floor, walls, and ceilings) Masonry (concrete block or solid brick walls) Frame (wood walls)

46. What material is the roof made of?

Shingles Tiles Metals Concrete

47. If this property is more than 20 years old, when is the last time you renovated the Roof?

48. If this property is more than 20 years old, when is the last time you renovated the Plumbing?

49. If this property is more than 20 years old, when is the last time you renovated the Electrical Wiring?

50. If this property is more than 20 years old, when is the last time you renovated the Heating/Air Conditioning Unit?

52. Do you have any structures that are not attached to the main property?

Garage Carport Guest Home Shed Storage Unit (offsite) Other (Fence gazebo, waterfall, greenhouse)

55. If you have a pool, do you have a protective barrier surrounding your pool?

Fence Pool Enclosure

56. Do you have a Fireplace or Wood Stove?

Yes No

If yes, is it Electric or Gas?

58. What was the purchase price of your property?

59. What is the Replacement Cost value of your property less land value?

60. Do you have any jewelry, fine arts, silverware, furs, etc. that need to be scheduled?

61. Do you have a Flood Policy in place?

62. Do you have a Flood Elevation Certificate for this property?

63. Do you have completed Mitigation Forms for this property?

64. Do you own any other properties we are not insuring?

65. Any additional comments?

By checking this box, you certify that all information provided is accurate.

Are you currently a client of IRMS?

Yes No

If yes, who is your agent:

Dawn Zettler Inge Hutson Joann Whitney None

If no, have you spoken to any of the following agents?

Dawn Zettler Inge Hutson Joann Whitney None

Naples: 8950 Fontana Del Sol Way, Suite 200 | Naples, Florida 34109
Phone: 239-649-1444 | Fax: 239-649-7933
Fort Myers: 9530 Marketplace Road, Suite 205 | Fort Myers, Florida 33912
Phone: 239-275-0151 | Fax: 239-275-0272

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Trusted Choice® Pledge of Performance

Trusted Choice® agencies are insurance and financial services firms whose access to multiple companies and commitment to quality service enable us to offer our clients competitive pricing, a broad choice of products and unparalleled advocacy.

As a Trusted Choice® agency, we are dedicated to you and are committed to treating you as a person, not a policy. This commitment means we shall:

Work with you to identify the insurance and financial services that are right for you, your family or your business and use our access to multiple companies to deliver those products.
Guide you through the claims process for a prompt and fair resolution of your claim.
Help you solve problems related to your coverage or account.
Explain the coverages and options available to you through our agency, at your request.
Return your phone calls and e-mails promptly and respond to your requests in a timely manner.
Provide 24/7 services for our customers, offering any or all of the following: emergency phone numbers, Internet account access, e-mail and call center services.
Use our experience and multiple company relationships to customize your coverage as needed.
Commit our staff to continuing education so they may be more knowledgeable in serving you.
Treat you with respect and courtesy.
Conduct our business in an ethical manner.

We pledge this to you, our clients and ask that you let us know if we fail to meet our commitment, so we may take corrective action.

Simply selling insurance is not enough!®

Homeowner Insurance Survey

Trusted Choice® Pledge of Performance

Simply selling insurance is not enough!^®